Kjell Matre

More re-operations after uncemented than cemented hemiarthroplasty used in the treatment of displaced fractures of the femoral neck: An observational study of 11 116 hemiarthroplasties from a national register

Using data from the Norwegian Hip Fracture Register, 8639 cemented and 2477 uncemented primary hemiarthroplasties for displaced fractures of the femoral neck in patients aged > 70 years were included in a prospective observational study. A total of 218 re-operations were performed after cemented and 128 after uncemented procedures. Survival of the hemiarthroplasties was calculated using the Kaplan-Meier method and hazard rate ratios (HRR) for revision were calculated using Cox regression analyses. At five years the implant survival was 97% (95% confidence interval (CI) 97 to 97) for cemented and 91% (95% CI 87 to 94) for uncemented hemiarthroplasties. Uncemented hemiarthroplasties had a 2.1 times increased risk of revision compared with cemented prostheses (95% confidence interval 1.7 to 2.6, p < 0.001). The increased risk was mainly caused by revisions for peri-prosthetic fracture (HRR = 17), aseptic loosening (HRR = 17), haematoma formation (HRR = 5.3), superficial infection (HRR = 4.6) and dislocation (HRR = 1.8). More intra-operative complications, including intra-operative death, were reported for the cemented hemiarthroplasties. However, in a time-dependent analysis, the HRR for re-operation in both groups increased as follow-up increased. This study showed that the risk for revision was higher for uncemented than for cemented hemiarthroplasties.

Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures. A study of 2716 patients in the Norwegian Hip Fracture Register.

BACKGROUND Intramedullary nailing is commonly recommended as the treatment of choice for transverse/reverse oblique trochanteric (AO/OTA type A3=intertrochanteric) and subtrochanteric fractures. However, only to a limited extent is this approach supported by superior results in well designed clinical trials, and the sliding hip screw (SHS) is still a frequently used implant for these fractures. The aim of the present study was to compare IM nails and SHS in the treatment of transverse/reverse oblique trochanteric and subtrochanteric fractures using data from the Norwegian Hip Fracture Register (NHFR). METHODS Data on 2716 operations for acute transverse/reverse oblique trochanteric or subtrochanteric fractures were collected from the NHFR from 2005 to 2010. Surgeons reported patient characteristics and details from initial surgery and reoperations, and patients answered questionnaires about pain, satisfaction, and quality of life (EQ-5D) 4, 12, and 36 months postoperatively. Reoperation rates were calculated using Kaplan-Meier analyses. Primary outcome measures were pain (Visual Analogue Scale (VAS)), satisfaction (VAS), quality of life (EQ-5D), and reoperation rates at one year. RESULTS The treatment groups were similar regarding age, gender, ASA-class, cognitive impairment, and preoperative EQ-5Dindex score. At one year reoperation rates were 6.4% and 3.8% for SHS and IM nails, respectively (p=0.011). Patients treated with SHS also had slightly more pain (VAS 30 vs. 27, p=0.037) and were less satisfied (VAS 31 vs. 36, p=0.003) compared to patients treated with IM nail. There was no statistically significant difference in the EQ-5Dindex score, but the mobility was significantly better for the IM nail group. CONCLUSION 12 months postoperatively patients with transverse/reverse oblique trochanteric and subtrochanteric fractures operated with a SHS had a higher reoperation rate compared to those operated with an IM nail. Small differences regarding pain, satisfaction, quality of life, and mobility were also in favour of IM nailing. Consequently, a change in our treatment strategy for these fractures could be considered.

TRIGEN INTERTAN Intramedullary Nail Versus Sliding Hip Screw A Prospective, Randomized Multicenter Study on Pain, Function, and Complications in 684 Patients with an Intertrochanteric or Subtrochanteric Fracture and One Year of Follow-up

BACKGROUND Both intramedullary nails and sliding hip screws are used with good results in the treatment of intertrochanteric and subtrochanteric fractures. The aim of our study was to assess whether use of the TRIGEN INTERTAN nail, as compared with a sliding hip screw, resulted in less postoperative pain, improved functional mobility, and reduced surgical complication rates for patients with an intertrochanteric or subtrochanteric fracture. METHODS In a prospective, randomized multicenter study, 684 elderly patients were treated with the INTERTAN nail or with a sliding hip screw with or without a trochanteric stabilizing plate. The patients were assessed during their hospital stay and at three and twelve months postoperatively. A visual analogue scale (VAS) pain score was recorded at all time points, and functional mobility was assessed with use of the timed Up & Go test. The Harris hip score (HHS) was used to assess hip function more specifically. Quality of life was measured with the EuroQol-5D (EQ-5D). Radiographic findings as well as intraoperative and postoperative complications were recorded and analyzed. RESULTS Patients treated with an INTERTAN nail had slightly less pain at the time of early postoperative mobilization (VAS score, 48 versus 52; p = 0.042), although this did not influence the length of the hospital stay and there was no difference at three or twelve months. Regardless of the fracture and implant type, functional mobility, hip function, patient satisfaction, and quality-of-life assessments were comparable between the groups at three and twelve months. The numbers of patients with surgical complications were similar for the two groups (twenty-nine in the sliding-hip-screw group and thirty-two in the INTERTAN group, p = 0.67). CONCLUSIONS INTERTAN nails and sliding hip screws are similar in terms of pain, function, and reoperation rates twelve months after treatment of intertrochanteric and subtrochanteric fractures.

Clinical outcome after undisplaced femoral neck fractures

Background and purpose Little attention has been paid to undisplaced femoral neck fractures. By using data from the Norwegian Hip Fracture Register, we investigated the risk of reoperation and the clinical outcome after treatment of these fractures in patients over 60 years of age. Methods Data on 4,468 patients with undisplaced femoral neck fractures who were operated with screw osteosynthesis were compared to those from 10,289 patients with displaced femoral neck fractures treated with screw osteosynthesis (n = 3,389) or bipolar hemiarthroplasty (n = 6,900). The evaluation was based on number of reoperations and patient assessment at 4 and 12 months of follow-up. Results The 1-year implant survival was 89% after screw fixation for undisplaced fractures, 79% after screw fixation for displaced fractures, and 97% after hemiarthroplasty for displaced fractures. Patients with displaced fractures who were operated with internal fixation had a higher risk of reoperation (RR = 1.9, CI: 1.7–2.2), reported more pain, were less satisfied, and had lower quality of life than patients with undisplaced fractures treated with internal fixation (p < 0.05). Patients with displaced fractures who were operated with hemiarthroplasty had a lower risk of reoperation than patients with undisplaced fractures who were operated with internal fixation (RR = 0.32, CI: 0.27–0.38). Furthermore, they had the lowest degree of pain, were most satisfied, and reported the highest quality of life. Interpretation The differences in clinical outcome found were less than what is considered to be of clinical importance. The results support the use of screw osteosynthesis for undisplaced femoral neck fractures in elderly patients, although even better results were obtained in the hemiarthroplasty group in patients with displaced fractures.

Intramedullary Nails Result in More Reoperations Than Sliding Hip Screws in Two-part Intertrochanteric Fractures

BackgroundSliding hip screws (SHSs) and intramedullary (IM) nails are well-documented implants for simple two-part intertrochanteric fractures; however, there is no consensus regarding which type of implant is better.Questions/purposesWe asked whether patients with simple two-part intertrochanteric fractures treated with IM nailing had (1) a lower reoperation rate and (2) less pain and better quality of life than patients treated with SHSs.MethodsWe used data from the Norwegian Hip Fracture Register on 7643 operations for simple two-part intertrochanteric fractures (AO/OTA Type A1) treated with an SHS (n = 6355) or an IM nail (n = 1288) between 2005 and 2010. Kaplan-Meier analysis was used to assess reoperation percentages and a Cox regression model was used to assess the risk of reoperation. Questionnaires regarding pain and quality of life were answered by the patients at 4, 12, and 36 months postoperatively.ResultsWe found an increased risk of reoperation after IM nailing within 1 postoperative year: 2.4% and 4.2% for SHS and IM nails, respectively. The difference persisted with time: 4.5% and 7.1% at 3 years. We also found minor differences for pain and quality of life which we judged clinically unimportant.ConclusionsBased on our findings and a critical review of the literature, we suggest an SHS is likely the preferred implant for simple two-part intertrochanteric fractures.Level of EvidenceLevel III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Improved outcome after hip fracture surgery in Norway

Background and purpose — The operative treatment of hip fractures in Norway has changed considerably during the last decade. We used data in the Norwegian Hip Fracture Register to investigate possible effects of these changes on reoperations and 1-year mortality. Patients and methods — 72,741 femoral neck (FFN) fractures and trochanteric fractures in patients 60 years or older were analyzed. The fractures were divided into 5 time periods (2005–2006, 2007–2008, 2009–2010, 2011–2012, 2013–2014). Cox regression models were used to calculate unadjusted and adjusted (age group, sex, and ASA class) relative risks (RRs) of reoperation and of 1-year mortality in the different time periods. Results — For undisplaced FFNs treatment with hemiarthroplasty increased from 2.1% to 9.7% during the study period. For displaced FFNs treatment with arthroplasty increased from 56% to 93%. The use of intramedullary nails increased from 9.1% to 26% for stable 2-fragment (AO/OTA A1) trochanteric fractures, from 15% to 33% for multifragment (AO/OTA A2) trochanteric fractures, and from 27% to 61% for intertrochanteric fractures (AO/OTA A3)/subtrochanteric fractures. Compared with the first time period the adjusted 1-year RR for reoperation was 0.43 (95% CI: 0.37–0.49) for displaced FFNs in the last time period. The adjusted 1-year mortality in the last time period was lower for all fractures (RR: 0.87 (0.83–0.91)), displaced FFNs (RR: 0.86 (0.80–0.93)), AO/OTA A1 trochanteric fractures (RR: 0.79 (0.71–0.88)), and AO/OTA A2 trochanteric fractures (RR: 0.87 (0.77–0.98)) when compared with the first study period. Interpretation — Hip fracture treatment in Norway has improved: The risk of reoperation and the 1-year mortality after displaced femoral neck fractures have decreased over a 10-year period. National registration is useful to monitor trends in treatment and outcomes after hip fractures.

Evaluation of Timed Up and Go Test as a tool to measure postoperative function and prediction of one year walking ability for patients with hip fracture

Objective: To evaluate if the Timed Up and Go Test is a useful tool to measure postoperative function and to predict one-year results of rehabilitation in patients operated owing to hip fracture. Design: Prospective cohort study. Setting: The department of orthopaedic surgery at five hospitals in Norway. Patients were assessed five days postoperatively and after one year. Subjects: A total of 684 patients over 60 years with trochanteric or subtrochanteric hip fractures were included. A total of 171 (25%) patients died within a year and 373 (73% of patients still alive) attended follow-up one year after surgery. Main measures: Timed Up and Go Test and walking ability. Results: A total of 258 (38%) patients passed the postoperative Timed Up and Go Test. A total of 217 (56%) patients with a prefracture independent outdoor walking ability, passed the test. The average Timed Up and Go Test score was 71 seconds. A total of 171 (25%) patients could not rise from a chair without assistance; 8% of the patients with cognitive impairment, and 8% of those admitted from nursing homes, were able to pass the postoperative Timed Up and Go Test. The sensitivity and specificity of the Timed Up and Go Test in predicting walking ability one year after the operation were low. At one year follow-up, 38% of the patients not able to perform the postoperative Timed Up and Go Test, passed the test. A total of 81 (21%) patients did not use any walking-aid, 17 of them did not pass the postoperative Timed Up and Go Test. Conclusion: The Timed Up and Go Test performed the fifth postoperative day was not a suitable tool to assess functional mobility for the majority of the patients with hip fractures in our study. Neither was the postoperative Timed Up and Go Test a suitable tool to predict the walking ability one year after the operation.

Reply to Letter to the Editor: Intramedullary Nails Result in More Reoperations Than Sliding Hip Screws in Two-part Intertrochanteric Fractures

We thank Drs. Akcay, Satoglu, and Kurtulmus for their response to our article [2]. We agree that analyses of the patients’ radiographic images would add important information to the question whether intramedullary nails or sliding hip screws should be the preferred implants for trochanteric fractures. Valuable information also would be added if we could access patient files to correlate clinical findings to radiographic and overall outcome. We appreciate their idea of separately addressing the reasons for reoperations, and will consider future studies as they described. Preferably, radiographs and files from patients with and without complications or reoperations should be analyzed in such studies to address the reasons for failure in detail. This would enable us to better characterize failures and relate them to the initial fracture reduction and implant position (such as the tip-apex distance). However, in a large hip fracture registry including thousands of patients, collecting, classifying, and analyzing radiographs and patient files would be a major challenge and add a substantial workload to those running the registry and to all colleagues and hospitals reporting data to the registry. In our opinion, a well-performed, randomized, controlled trial, including the radiographic analyses suggested by Drs. Akcay, Satoglu, and Kurtulmus probably would be the best way to distinguish between implant and surgeon-related causes for reoperations. We recently published such a study including almost 700 patients [3]. Finally, despite that treatment with the sliding hip screw is considered the gold standard for this fracture type, the number of operations with intramedullary nails for simple two-part trochanteric fractures is increasing [1, 4]. Therefore, registry data as presented in our article need to be published, and the evidence-based bottom line should not be forgotten.